Limitations of quantitative research in the study of structural adjustment

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Soc. Sci. Med. Vol. 42, No. 3, pp. 313-324, 1996 Copyright ~\ 1996 Elsevier Science Ltd

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LIMITATIONS OF QUANTITATIVE RESEARCH IN THE STUDY OF STRUCTURAL ADJUSTMENT

P A T R I C I A L U N D Y

School of Social & Community Sciences, University of Ulster, Magee College. Londonderry, Northern Ireland

Abstract--Sociologists and, more recently, critical medical anthropologists have been arguing for a refocusing of the analysis of health and health care towards a perspective which considers the broader global political economy. In the context of the debt crisis and IMF/World Bank-inspired structural adjustment policies, the political economy theoretical perspective is becoming even more relevant in the analysis of health underdevelopment in many "Third World" countries. This study focuses on the direct and indirect effects of the Jamaican debt crisis and structural adjustment programmes on health care services and health standards. In this paper it is argued that there are methodological problems using quantitative data when studying the effects of structural adjustment. In addition to providing a limited account of the effects, it is argued that the basic problem is a matter of the availability and reliability of the quantitative data in many "Third World" countries. It is argued that some of these problems could be overcome by the application of qualitative micro-level analysis. This type of methodology is important to ascertain the effects of global processes at the grass roots level and to gain insights into what those working in the health sector are experiencing and what they perceive as the effects, if any, of structural adjustment policies. This has often been missing from the impersonal accounts offered by quantitative research on the subject to date.

Key words Jamaica, health underdevelopment, structural adjustment, quantitative, qualitative methods

INTRODUCTION: A GLOBAL POLITICAL ECONOMY PERSPECTIVE

Sociologists and more recently critical medical anthropologists have been arguing for a refocusing of the analysis of health and health care towards a perspective which considers the broader global political economy [1]. The literature on health in underdeveloped countries is vast and incorporates a wide range of disciplines. However, much of the literature produced by academics and international agencies can be criticised for failing to address the underlying causes of health problems adequately. As Navarro has argued, much of the literature is rich in description and lacking in theoretical analysis [2]. Rather than focusing attention strictly on national level internal factors, health related issues must be considered in a macro-analytical global framework.

Processes of globalisation make the political economy macro-analytical framework an increasingly relevant perspective. As Elling [3] has pointed out, there are whole sets of national and international health problems which might be better understood as interrelated problems of exploitation between core capitalist nations and peripheral nations. Globalisation does not mean equalisation. To ignore historical unequal global economic processes and the effects they may have on shaping health developments is, by exclusion, attributing current health problems to internal circumstances

and to individuals and groups in underdeveloped countries.

While arguing the merits of a global perspective, I would stress that it is also important for research- ers to analyse the 'on the ground' consequences for, and the responses of, local populations to broader global processes. Quite often political economists ignore micro-level analysis. They fail to present an account of life and social action at the grass roots level to substantiate their theoretical claims and broad geueralisations. As Singer [4] has rightly pointed out, we should be concerned with synthesiz- ing the macro-level understandings of the political economy with the micro-level sensitivity and aware- ness of conventional anthropology.

BACKGROUND

Jamaica is a former British colony which gained independence in 1962. The island is located in the Greater Antilles, approximately 90 miles south of Cuba, 100 miles west of Haiti and 600 miles south of Miami. It is the third largest island in the Caribbean. The population in 1990 was estimated at 2.5 million, about 50% of whom live in urban areas. It is a small, dependent, capitalist economy based on agriculture, bauxite, tourism and light industry. A very large percentage of what Jamaica produces is exported rather than used locally, while a high proport ion of what the society consumes is

313

314 Patricia Lundy

imported from abroad. Most Jamaicans are poor with an average GNP per head of approximately U.S.$1200. Moreover, income distribution is extremely uneven. According to World Bank estimates, the top 20% of the population account for more than 60% of income [5]. In addition, Jamaica is now one of the most indebted countries in the world. The country's total external debt in 1991 was approximately $4.5 billion dollars. This amounts to U.S.$1800 for every man, woman and child on the island [6].

Over tbe past few decades, health standards in Jamaica have come to rank among the best in the 'Third World'. The average life expectancy is estimated at 73 years, which compares extremely well with the U.S. figure of 76 and the average Haitian's life expectancy of 55 years [7]. Along with improvements in health standards has come a shift in disease incidence away from infectious diseases towards chronic diseases among adults similar to those in industrialised countries. The leading causes of death are cerebro-vascular disease, heart disease, and cancer [8]. However, despite the changes in patterns of disease among adults, the pattern of ill- health among children remains one which more clo- sely resembles underdeveloped countries. The major killer in the under five age group is diarrhoeal disease. Infectious diseases and nutritional deficiencies are also major causes of morbidity and mortality for children [9].

The health care system was inherited from the colonial era and is a predominantly western style curative hospital-based model. During the 1970s under the socialist Peoples National Party (PNP), emphasis was placed on promoting primary health care programmes [10]. During these years there was an expansion of health centres islandwide and the introduction of a new type of worker, the community health aide (CHA) [11]. Jamaica's public health system includes a well-developed hospital, clinic and environmental health network. The overall policy goal of the Ministry of Health under the conserva- tive Jamaica Labour Party (JLP) in the 1980s was to "'ensure equitable access to at least the basic level of health care by the whole population" [12]. However, a spatial imbalance in favour of urban areas in the availability of both hospital and PHC clinics continues to exist islandwide [13].

ECONOMIC CRISIS

During the 1970s almost all countries in the Caribbean reflected the economic problems of small, petroleum-importing, dependent economies facing unstable world markets. In the wake of OPEC-induced oil crises, which led to a m a s s i v e

increase in oil and energy-related costs, Jamaica experienced rising inflation from the early 1970s

onward. A further misfortune for Jamaica was the decrease in demand in North America for their

major export earner, bauxite, and a decline in the tourist industry after the mid-1970s. Because of the heavy dependence on bauxite and tourism as foreign exchange earners, Jamaica's balance of trade deteriorated sharply between 1975 and 1977. In addition, foreign investment declined while capital flowed out. The tempting international loan cli- mate led Jamaica to borrow to tide over its difficulties. The national debt rose dramatically from U.S.$124 million in 1970 to U.S.$489 million in 1979 [14].

The economic crisis was a major reason for the defeat of the PNP in the 1980 general election and its replacement by the JLP. The JLP was recognised to be much more oriented towards free market economic policies as advocated by the IMF/World Bank than its PNP predecessor. The JLP faced a most severe economic situation, with an economy in recession, high unemployment, massive levels of emigration, capital flight, external debt arrears and a critical shortage of foreign exchange. The new government undertook further borrowing to see itself through these problems. Nevertheless, Jamaica's economy continued during the 1980s to be dogged by factors such as a high balance of pay- ments deficit, a heavy debt burden and low export commodity prices. As a result of escalating economic decline, the international financial institutions imposed a "shock treatment" of structural adjustment measures in the mid-1980s.

WHAT IS STRUCTURAL ADJUSTMENT AND WHY IS IT CONTROVERSIAL?

Structural adjustment is a term which is frequently used to describe a programme or package of economic reforms advocated by the World Bank and the IMF, often associated with heavily indebted 'Third World' countries. The international financial institutions insist that before any country can draw on their assistance it must implement a structural adjustment package (SAP). These policies are essen- tially designed to release more of 'Third World' resources to service their debts. Despite the wide diversity and variety in the 'Third World', there is a close similarity between the terms of the various structural adjustment packages.

Typically these measures require a devaluation of the currency, wage controls, tax increases and emphasis on export-led growth and import liberali- sation. Other measures include privatisation of government enterprises and an emphasis on increasing the profitability of remaining state enterprises such as water, electricity and transport. Among the most directly damaging effects of SAPs are reductions in government spending on public and social serv ices

and the reduction or elimination of subsidies on food and other essentials. In this context structural adjustment and stabilisation policies have been

Limitations of quantitative research 315

linked to negative impacts on human welfare [15] and environmental deterioration [16].

T H E S O C I A L ~ E L F A R E D E B A T E

There has been considerable debate about the role of the IMF/World Bank and the structural adjustment programmes they promote. Some economists have criticised the effectiveness of such programmes [17], while those from other disciplines have highlighted the negative social costs of adjustment [15]. It has been argued that the stabilisation and structural adjustment programmes supported by the World Bank and IMF have focused nar- rowly on economic problems, with little or no attention paid to the social consequences of such policies. While tailing to bring about econornic growth, it has become apparent that such programmes have imposed a harsh burden on the poor and have resulted in a lowering of levels of human welfare in many underdeveloped countries. This was highlighted by the two-volume UNICEF study Adjustment with a Human b~tce. UNICEF's con- clusion was that the welfare of children (and by im- plication, the poor and the society at large) declined in the 1980s. The study attributes this deterioration, at least in part, to the implementation of stabilisation programmes and structural adjustment policies. Besides the UNICEF study, a variety of research has been carried out in the 1980s which supports the argument that adjustment falls more heavily on the poorer sections of society and has resulted in a deterioration in social welfare [18]. It has become evident that many countries with adjustment programmes have reduced public expenditure on social services, cut back on public sector

employment and have experienced higher unem-

ployment. Wage levels have eroded dramatically in

many such countries and social wellare has suffered

[191. In response, the World Bank and IMF commis-

sioned their own case studies, in which they set out to refute such claims and those of the UNICEF study in p~rticular. They state that, having pro- yoked a more balanced examination of the issues. the almost systematically "'gloomy view" of

Adjustment with a Human Face is now being par-

tially rebutled. In one World Bank report it was stated that, "'we do not see these studies as having

demonstrated that economic adjustment policies

have had deleterious effects on health and nutrition

in developing countries or that health and nutrition would haw: been substantially better without the

economic adjustment policies or with different econ-

omic adjuslment policies" [14, p. 26]. In addition. they insulate themselves from the consequences of

their policies by arguing that the setting of social and political priorities is a matter l\)r governmenls. and not for them.

The studies aimed at assessing the impact of structural adjustment on local populations take what is generally known as the 'welfare approach',

which focuses on human welfare "outputs" and attempts to relate these to institutional "inputs'.

One of the major difficulties when analysing the effects of structural adjustment, whether on the en-

vironment or on human welfare, is the difficulty in establishing direct causality. In this debate, the available social indicators and quantitative data have played a prominent role, despite their acknowledged limitations.

10.00 l

9.00

8.00

7.00

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4.00 ]

3.00 i

2.00; I

1.00 i 0.00 !

7 ~

I

85/86 86/87 82/83 83/84 84/85 87/88 88/89

YEAR

89/90 90/91

E ~] % Recurrent I l l % Capital

Fig. I. Health expenditure 1982 1991 as a percentage of national budget. Source: Compiled from Annual Estimates ~!/ Exlu'nditure. Ministry of Health 1982 1991.

316 Patricia Lundy

7.0001

6,000 t

4,000[ 3,000~

2,000

1,000

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989

YE~M,~

Registered Nurses m Doctors ~_.] Student Nt~ses ~-f~l CHA's ~ Other

Fig. 2. Number of health personnel, Jamaica 1980 1990. Source: Social and Economic Survey, Planning Institute of Jamaica. various years.

1990

THE SOCIAL COSTS OF ADJUSTMENT

One incontrovertible indicator of a decline in health input in Jamaica is the percentage decrease in government expenditure on health which resulted from structural adjustment. This is illustrated by Fig. 1, which depicts the relative change in capital and recurrent expenditure. The decrease of total government expenditure on health was from a 7.45% share of the national budget in 1982/83 to a low point of 5.05% in 1986/87 [20]. This represents a cut of one third of total health spending over the period. Real per capita outlays on health declined from U.S.$44 in 1982/83 to U.S.$25.6 by 1986/87 a reduction of 42%. As a percentage of GDP, health expenditure declined from 3.6% in 1982 to 2.2% in 1986, rising to 2.7% in 1987 [6, p. 5t)].

In addition to cuts in the health budget, a significant reduction occurred in the overall numbers of personnel employed in the health services, as illustrated in Fig. 2. This shows an overall decrease from a total of 6329 employees in 1980 to a total of 3603 in 1990. A particularly notable decline is in the number of nurses, from 2524 in 1975 to 973 in 1990 [21]. At the same time, a process of divesting non-medical services in the major hospitals was launched with many public sector job losses resulting among ancillary staff.

A sharp drop in the number of community health aides is a particularly notable feature of this time. While 1500 public employees in the health sector were made redundant in 1985, health aides bore the brunt of cuts with a reduction of their numbers from 1168 in 1984 to 555 in 1985, and a further reduction to 386 in 1986 [21]. The CHAs played an important role in outreach primary health care in the poorest communities and particularly in rural

areas which were least well catered tbr by public health services.

During the 1980s there was a steady deterioration in terms of the ratio of selected categories of health workers to the growing Jamaican population. In 1990 there was a ratio of one doctor for every 6406 people [22]. The World Health Organisation's recommended ratio of doctors to population is one for every 910 people, meaning that the Jamaican ratio had become one seventh of the ideal figure. In the case of nurses, the WHO's recommended ratio is one nurse for every 769 people, in 1990 the nurse population ratio in Jamaica was 2482 people to every nurse [22, p. 20], or approximately one third of the ideal figure. It should be noted that these national ratios do not reflect the maldistribution of medical personnel in favour of urban areas and that ratios for rural areas are considerably worse. Moreover the quantitative data also do not reveal how the shortages of health professionals and cuts in the health budget are affecting the Ministry of Health's ability to provide adequate services.

From the quantitative data presented it has been shown that structural adjustment has reduced the health budget and has affected directly and indirectly staffing levels in the public health sector. However, the World Bank asks if this is a bad thing [30]. They say that lower expenditure should encou- rage greater efficiency within the health sector. In a recent report it was stated that, "'because resources will continue to be very scarce, increased coverage and quality of social service delivery cannot be expected to result fiom growth in expenditures. Rather improvements in service delivery must come from increasing the equity and efficiency of resource use" [30]. The qualitative data presented in the final section of this paper throws doubt on the World


Bank's view that greater efficiency will compensate for fewer resources.

LINKING INPUTS WITH OUTCOMES 1N HEALTH

Nutritional status is the most important indicator of social welfare and the most responsive to recession and adjustment [24]. Rising inflation, increasing food prices and the removal of food subsidies obviously exacerbate the hardship of the poor and low wage earners. Structural adjustment programmes are characterised by increases in the general level of domestic prices of food and other basic necessities. This is usually the result of currency devaluation which leads to increases in import prices, generating increases in all other domestic prices. Successive devaluations have had a serious effect on the least well off groups in society because in Jamaica the basic components of the food basket of poor consumers--flour, cornmeal, rice--are imported. In addition, during the 1984-86 period food subsidies were removed in compliance with the IMF adjustment programme.

Estimates of malnutrition rates based on weigh- ing and measuring children who attend clinics are frequently used by policy-makers to follow trends in malnutrition, and to inform policy and programme decisions which could affect malnutrition rates. The data are used because they are the most available, recent, and inexpensive to collect. However, in Jamaica they may be significantly biased. Grosh et al. [25] compare annual clinic- based malnutrition data with those from four household surveys in Jamaica. The clinic data give lower estimates of malnutrition than the survey data in all four cases--significantly so in three. The size of the bias was variable over time, so the clinic data were not a good indicator of either levels or trends in nutritional status. Since clinic-based estimates of malnutrition rates are biased and unreli- able, it is unlikely that they will represent the 'true' malnutrition rate in Jamaica.

Table 1 illustrates household survey data on malnutrition rates. The survey data is said to be as good an estimate of malnutrition rates as is likely to be obtained in Jamaica [25, p. 7]. Malnutrition rates, as defined by Gomez grades I and lI, declined as indicated in survey years 1978, 1985 and 1989. Malnutrition rates, as defined by Gomez grade III, rose from 0.8 in 1978 to 1.3 in the third quarter of 1989. A major problem with survey data is, how-

Table 1. Malnutrition rates based on household survey data

Year Normal Grade I Grade II Grade Ill

1978 60.2 32.2 6.5 0.8 1985 63.3 29.3 6.2 1.2 1989

Q.3 70.0 25.6 3.1 1.3 Q.4 71.2 25.6 2,5 0.7

Source: Adapted from [25].

Table 2. Admissions of children 0--59 months for malnutrition and maInutrition/gastroenteritis to Bustamante Children's Hospital

1978-1985 by number and percentage of total admissions

Malnutrition/ Malnutrition gastroenteritis

Year (N) (%) (N) (%)

1978 68 1.9 55 1.6 1979 91 2.2 69 1.7 1980 98 1.7 58 10 1981 110 2.8 90 2.] 1982 86 2.2 75 1.9 1983 98 2.1 95 2.{I 1984 110 2.4 122 2.7 1985 124 3.7 16(1 4.7

Source: Cited in [26].

ever, their infrequency, which does not allow for the level nor trend of malnutrition to be estimated in the years between surveys.

Using other sources of data, as part of the UNICEF study Boyd [26] analysed malnutrition levels in Jamaica during the severest structural adjustment period 1983 1985 and identified a significant increase. He used data from admissions for malnutrition to Jamaica's national paediatric hospital. According to him, as illustrated in Table 2, the percentage of hospital admissions for malnutrition increased from 1.9% in 1978 to 3.?% in 1985 and that admissions with malnutrition and gastroenteritis increased from 1.6% to 4.7% in the same three year period. He concludes that both the number and relative frequency of cases of malnutrition and malnutrition/gastroenteritis have increased considerably since the application of the stabilisation programme. However, the limited data on malnutrition is conflicting and could be used to support oppos- ing arguments.

Certain indicators are not of value to a study of short term effects of structural adjustment. For example, the Jamaican life expectancy figure remains high, and it would take a number of years to assess what effect, if any, the changes of the 1980s have on it. It is more valid, perhaps, to look at the state of child mortality, crude death rate and maternal health. However, as with malnutrition rates there are problems with availability and accuracy of quantitative data for these output indicators.

In terms of the crude death rate, which has improved slowly over this century, the figures for the last decades do not reveal any significant devi- ation as indicated in Table 3, Under-five mortality rates are considered by UNICEF as the best indicator of social development. However, neither the magnitude of nor the trends in infant mortality have been adequately measured in Jamaica in the past decade [27]. A number of studies have found evidence of significant under reporting of infant deaths [28]. However according to World Bank estimates infant mortality rates in Jamaica have stea-

318 Patricia Lundy

Table 3. Death rate and infant mortality rate, Jamaica 1970-1988

Year 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988

Deaths 7.7 7.2 7.2 7.1 5.9 5.8 5.6 5.9 5.7 5.2 IMR 39.6 36.0 31.6 27.2 24.2 22.6 21.0 19.8 18.6 na

n/a--not available for that year. Source: Rate: Statistical Yearbook, STATIN (Statistical Institute of Jamaica), various years: [19].

dily declined as indicated in Table 3. Trends in maternal health are also inconclusive as seen in the most recent statistics available. A compilation of the figures found in separate studies was tabulated by the Ministry of Health and are presented in Table 4. Again caution should be exercised when considering this data because studies have indicated that maternal mortality rates are underestimations [29].

From analysis of available quantitative data it would appear that despite the negative changes in inputs there does not seem to be any clear trend or decline in health output indicators, apart from the increase in rates of malnutri t ion for children as shown in Table 2. Is this because health changes have not occurred or because they are simply not showing up in the official statistics?

METHODOLOGICAL PROBLEMS AND LIMITATIONS OF QUANTITATIVE DATA IN THE STUDY OF SOCIAL

WELFARE DECLINE

As Zuckerman [19, p. 7] points out, mapping the impact of adjustment programmes on social welfare is difficult. Some feel that reliable analytical meth- odologies to do so have yet to be formulated. However, the basic problem is a matter of the availability and reliability of the data, and the problem of determining causality. Based on quantitative data, the anomaly is that, despite the cuts in social spending, rising inflation and removal of food subsidies, health indicators do not show deterioration to the extent that one might expect.

As Grosh [30] points out, there are a number of factors which might explain this situation. A simple explanation is that changes in the social indicators can be expected to lag considerably behind changes in the inputs. A 'lagged effect' may be partly due to past investment in education and infrastructure such as water and sanitation services. Moreover, once physical infrastructure and health systems have been established, they can be expected to function to at least some degree, even with reduced

funding. Some inputs into social progress are irre- versible, for example, immunisation. However, while this may be true, it does not mean that conti- nuing reduction in social services expenditure can be absorbed over the long run without impeding progress in health. The damage may already be caused but may not be noticeable for another few years or may not be showing up in official statistics. Therefore, decreased efforts now could result in stagnation or deterioration of social indicators in the next five to twenty years.

The household contribution is another factor to be considered. Anderson [31] is of the opinion that attempting to use the present social welfare framework to trace structural adjustment impacts is to miss a component. While adjustment measures will lower the purchasing power of the majority of individuals in the society, these individuals may respond in a variety of ways, and it is these responses which will determine whether welfare will decrease or not. Anderson [31, p. 8] argues that, structural adjustment is a particularly violent source of social change, and its effects must be traced both at the level of system inputs and outputs and at the beha- vioural level. An example is that the removal of food subsidies represents a decreased input which has the effect of increasing the cost of the household food basket. However, household members may respond by reducing consumption, seeking additional income, perhaps in the informal economy, changing their dietary patterns, and by reducing savings. The net effect of these responses will determine both whether welfare decreases, and whether there is a decrease in the human resources available for development.

There are other methodological problems in the analysis of the impact of structural adjustment. As Joekes [32] points out, in order to isolate the social impact of structural adjustment measures, there has to be knowledge of both the lagged effects of previous economic conditions and of the counterfac- tual situation (i.e. the situation which would have

Table 4. Maternal mortality rates, Jamaica 1980-1986

Year 1980 1981 1982 1983 1984 1985 1986

Maternal mortality rate per 100,000 deliveries 10.9 10.0 11.5 10.4 n/a n/a 10.8

n/a--not available for that year. Source: Situation Analysis-Health, Ministry of Health, 1989.


been obtained in the absence of the adjustment programme). Neither can be estimated exactly. In other words it is not possible to say whether the situation would have been better or worse without adjustment. Adjustment is required when there has been some change necessitating it. But separating the effects of the (normally adverse) change from those of the adjustment policies is extremely difficult. It is impossible to explore every possibility.

Furthermore, the other major problem in attempting to assess the impact of adjustment on health and health care provision is the paucity and unreliability of statistics. My own research illustrates the point. Jamaican official statistics stated in April 1992 that forty-three clinics were in operation in the KSA parish. After visits to various clinics, which were found not in fact to be operational, I estimated the actual number of functioning clinics at thirty-one. The favourable but inaccurate picture of the availability of primary health care clinics serves to illustrate the unreliability of official data and throws doubt on the Jamaican government's claim that 90% of the population lives within ten miles of a health centre.

The accuracy of measurement of social indicators is also probably quite low. Longitudinal data on welfare distribution are highly inadequate. Despite their acknowledged limitations, the available social indicators have played a prominent role in the welfare debate, However, because of methodological difficulties, the debate remains unresolved. It is clear that attempts usually flounder both because of measurement weaknesses in the selected indicators and because of the general difficulty in establishing causality. I would argue that, despite the lack of "hard data" reflecting deterioration in the chosen indicators either in health standards or health care provision, this does not necessarily mean that structural adjustment has not had a negative impact on health and the social infrastructure.

ALTERNATIVE DATA APPROACH AND ANALYTICAL METHODOLOGY IN THE STUDY OF HEALTH CARE

PROVISION

The World Bank and IMF maintain that their policies have had little negative impact on health care provision and social welfare in countries experiencing re-structuring. It is clear that insuffi- cient quantitative data exist to demonstrate other- wise. Despite the inconclusive evidence, however, many in the development community are in no doubt that adjustment has a harmful impact on those countries experiencing long-term adjustment programmes. In an effort to provide more insights into the effects of adjustment, I decided to carry out qualitative research in Jamaica. The aim of the research was to analyse what health professionals were experiencing and what they perceived to be

the effects of structural adjustment policies on health care provision during the 1980s. I felt that it was important to examine Jamaicans' perceptions of their own situation and that doing so would provide valid insights into the adjustment process.

Study site and background

Qualitative research was carried out in Jamaica from January to April 1992 as part of a broader research project. The research was located in the parish of Kingston and St Andrew (KSA) and focused principally on primary health care (PHC) services. Seventeen of the thirty-one PHC clinics in operation were visited across six health zones in the KSA parish. Semi-structured interviews were carried out with fifty-six randomly selected health professionals including physicians, nurses, CHAs, midwives and public health inspectors. Participant observation methods were used to cross-check the responses to the interviews and to directly observe conditions in clinics.

Clinic interviews were cross-checked against interviews with senior health officials from the Kingston Public Health Department, the Environmental Control Division (ECD), Underground Water Authority and other senior figures such as a former Minister for Health (1980- 89). In addition, personnel from the Pan American Health Organisation (PAHO) and officials from the National Resource Conservation Authority, which has responsibility for environmental matters throughout the island, were interviewed. The princi- pal aim of 1he interviews with senior officials was to explore what they considered to be the direct impact of adjustment policies on health services. Sixteen senior officials were interviewed in total in addition to the fifty-six clinic staff.

Accounts o[ structural adjustment from the grass- t o o l s

Few individuals who were interviewed in the course of the study expressed the view that public health care services and public health standards had not seriously declined over the past decade. Many attributed this decline to Jamaica's debt crisis and specifically to structural adjustment policies. Informants were of the opinion that the deterioration in the provision of public health services over the past decade, and particularly since the mid-1980s, was directly attributable to the deep cuts in social expenditure.

Quantitative data indicate that there are staff shortages in Jamaica. However the implications for the delivery of health services has rarely been explored. From the interviews it was clear that health professionals were unable to carry out the full range of duties associated with the primary health care model. As one nurse put it:

320 Patricia Lundy

The staff situation ... I don't even know what word to use now~r i t ica l is so mild. It reaches a point now where the centre is not holding ... you know, the thing is falling apart. It's not only the health sector, it's all the social infrastructure.

In fo rmants stated that pat ients have become dis- illusioned with the public health services, as they

repeatedly experience long waiting periods due to lack of staff and because the clinics lack adequate medical supplies. Heal th care professionals repeat-

edly spoke of shortages of drugs, vaccines, and even of basic supplies such as plastic gloves, soap and disinfectant. Three mon ths ' drugs provision was said to last only two or three weeks. Electricity was reportedly cut off in clinics on more than one oc-

casion l\)r months at a time because central office could not pay the bill. As one midwife put it:

We've gone so long now without the proper supplies if someone was to ask us what we need we wouldn't be able to tell them. We've got so used to getting by with so little and making do, you know ... we don't remember what we supposed to have.

Lack of basic resources had created widespread

feelings of helplessness and demoral isa t ion among members of clinic s taff who were interviewed. A public health nurse typified such feelings when she told me . . . :

I've just given up worrying ... it's not worth it. You write up the reports and list what you need and nothing ever comes o1 it. They just tell us there's no money. I've just given up trying. We ask patients to donate a little, that's how we get by ...

The financial const ra ints resulted not only in fail- ure to guarantee basic medical supplies, but also in lack of expenditure necessary to main ta in clinic buildings. As a result, many clinics have fallen into disrepair and some have become so di lapidated that they have had to close. F rom observat ion it was apparen t that many clinics which remain open require major repairs. Kingston and St Andrew consists of the largest u rban area in Jamaica but also sparsely populated moun ta inous rural districts. In the more remote areas, pr imary health care provision has been reduced to outreach services. Outreach services are provided for a few hours once or twice per week, or per month , in areas which have no permanent clinic or where the clinic is not used because of disrepair or because there are insuf- ficient staff to run it. The necessary equipment and personnel are dispatched from already overstretched clinics often many miles away.

The buildings used for the purposes of outreach services are often in extremely poor condit ion. Dur ing the research period I visited outreach services operat ing from premises including a church hall and a disused pr imary school. The premises lacked even the most basic amenities such as a water supply. On the days I visited the outreach 'clinics', pat ients had been waiting several hours until s taff and the necessary equipment could be

released from other funct ioning clinics. Official documents do not reveal that PHC services have been reduced to outreach status in part icular areas. The services in the respective areas are classified as normally funct ioning clinics, despite severe restric- tions in the level of service they provide.

Especially in the more remote areas of St Andrew, the uncer ta inty of pr imary health care services has resulted in patients by-passing public clinics in favour of private health care for those

who can afford it -and there is a preference for hospital t rea tment for even the most minor complaints. However, according to senior health officials, public hospi tal services have also been affected by the chronic shortages of resources and lack of nursing staff. They directly a t t r ibuted the

decline in nursing staff to structural adjus tment measures. As one senior health official explained:

At the Victoria Jubilee Hospital right now, 65% o[ the births are unattended. That's the largest maternity hospital on the island. I'm not sure what the tigure was ten years ago but it has drastically declined over the years, and it is directly proportional to the number of stall that are at work. The number of nursing staff at work is directly proportional to the effective income that those women get. A lot of nurses have been forced to leave nursing, to seek jobs elsewhere so they can get a living wage. Nursing no longer pays a living wage because of structural adjustment. Over the past fifteen years we have had wage guidelines, which means that your wages are kept down while the rest of the economy is allowed to float and to find its own market level. But wages can't find market level. They are kept down, so that you find you cannot live. The nurses live on their salaries. They are leaving nursing and as a result of that the shortages mean that even if you go to hospital you cannot get care you need.

The exodus of medical personnel is one of the most ou ts tanding features of the decade. While it is true tha t Jamaica has always had problems with its professionals emigrating, it would seem that structural adjus tment has intensified this situation. Structural ad jus tment has reduced the heal th budget and has affected directly and indirectly staffing levels and quality of services in the public health sector. Problems of inadequate salaries as a result of wage freezes, poor working condi t ions and the rising cost of living during the 1980s have resulted in even greater numbers of nurses and other health care professionals leaving the public sector for better paid jobs in the private sector or abroad. High salaries, good working condi t ions and vastly improved living s tandards are key reasons why hun- dreds of nurses leave Jamaica to work in countries such as the U.S.A. Given the costs of t raining heal th personnel, this results in a transfer of resources f rom one of the world 's most underdeveloped countr ies to one of the richest.

Heal th is influenced by factors other than formal heal th care delivery, with other government services such as water and sani ta t ion being perhaps the most impor tant . Responsibil i ty for envi ronmenta l heal th matters rests with the Envi ronmenta l


Cont ro l Division (ECD) of the Ministry of Health. ECD's functions include water quality control ,

domestic sewage and waste water control , air pol-

lution, occupat ional health, solid waste manage- ment and labora tory services. In addit ion, a number of o ther government agencies are involved at varying degrees in envi ronmenta l matters , such as the Nat ional Resource Conserva t ion Author i ty and the Nat ional Water Commiss ion (NWC).

According to officials at ECD, their depar tment has been adversely affected by structural ad jus tment

policies and budgetary cuts since the 1980s. As one senior official put it:

There has clearly been a deterioration of environmental regulation certainly during the "80s. If one looks at the status of the environmental agencies they've gone down, and what has happened to the personnel both in numbers and in quality. In fact one is actually going through a phase of trying to rebuild, h 's not possible to do it we don't haxe the rcsources.

Lack of resources has compounded already existing problems m the ECI) and created new ones by seriously reducing the capacity of the Depar tmen t to carry out its specific duties. This is part icularly true m the impor tan t area of regulation and monitoring. One official at ECD remarked:

Wc don't have the resources for research purposes, we don't have it for regular monitoring, we don't have it now l\~i" this regulatory arm. So it comes back to that. It's not that we don't know what is necessary. We don't have the where~iihal Ik~r physical, financial, human resources.

It became cleat" from the interviews that, at a time when depar tmenta l resources are shrinking en- v i ronmenta l problems are growing. According to informants , from 1978 to the present there has been a t remendous backward slide in public heal th conditions. Jamaica today is characterised by urbanis- at ion, rapid popula t ion growth, industrial development and modernisa t ion in agriculture. The combined consequences of all these factors exert considerable pressure on the general envi ronment , causing numerous envi ronmenta l heal th hazards. Complex problems are created by unregulated dis- charge and spread of industrial wastes into the en- v i ronment , carrying diverse pollutants. The increased consumpt ion of water in u rban areas gen- erates the need for stricter control of water quality. Likewise, the resulting increase in the product ion of sewage makes it imperative tha t sewage services be expanded, and sewage t rea tment properly controlled to avoid pollut ion of water courses.

The increasing problems and limited resources to deal with them tend to overwhelm the diminishing workt\wce. Officials described shortages of necessary equipment and t ransport . As one official remarked:

Well, equipment isn't working for years and this is key equipment which is vital for our work in water, sanitation and so on. You know it was PAHO who purchased it for us in the first place and we can't even maintain it. It took

from, let me see--January to April just to get two tyres for the jeep--all those months for just a few tyres. So we had no jeep. In fact while I was waiting for the tyres the battery went dead. You just can't function if you don't have transport it's a mess.

Even the most basic office supplies were unavail- able according to ano ther official:

Look. the government is giving us a straw basket to carry water in. We don't even have simple things . . . . like notebook yes bou ask anyone in the department not even a notebook. If you don't have even a simple thing like a notebook well?

According to staff, underfinancing, gross staff

shortages and inadequate equipment have undoubt - edly affected the quality of their operat ions and the

preventive work of the division. This si tuat ion has led to a high level of staff turnover and tow morale among those who stay. One in formant commented:

There is a big turnover in ECD. There's concern about environmental health from the government or tit least they say they're concerned. We've even asked the Permanent Secretary for transport and chemicals so we can do the job but we've had no response. The budget is a joke . . . . We can't get anybody to work m lhe Department. People come and they go after only a few months. I've been here about a year but I'm going myself.

Ano the r official remarked:

These kind of conditions, they wear you out, until the point that after one year two years you sa~. "'Listen, l like the environment, 1 like to protect the environment but working under these conditions is impossible" ...

ECD now works on a complaints system ra ther

than going out into the communi ty to moni to r and regulate envi ronmenta l heal th hazards. Health officials were unanimous in the view that a very serious

threat to public health has developed a round sea,- age, waste disposal and industrial pollution, particularly in the capital, Kingston, which is not being reflected in the official statistics.

An example of the dangerous slide in public health condi t ions is the official sewage system which has become overburdened as the u rban popula t ion

has expanded. Increasingly the Nat iona l Water Commiss ion is unable to meet this demand and several sewage t reatment plants are no longer able to

run at full capacity in Kingston. As a consequence, partially or untreated sewage is being discharged into Kingston Harbour . I visited Ha rbou r View communi ty in eastern Kingston where the sewage

t rea tment plant has been completely out of operat ion since 1986. A public heal th inspector informed me that dur ing the years in which the sewage plant has been out of operat ion, low water pressure and occasional blockage has culminated in episodes of flooding of households with sewage. Unt rea ted solid and liquid sewage discharges directly onto the site of the sewage plant. In addit ion, raw sewage flows untreated into the nearby Kingston H a r b o u r from the plant. A number of beaches along the ha rbou r shore are known to be unsafe for ba th ing because

322 Patricia Lundy

of con tamina t ion by untreated sewage, industrial and agricultural waste. Despite the reported dangers the beaches remain open to the public for rec- reat ional purposes, f ishermen still fish there and

people buy and consume the fish caught in the harbour. The unregulated pollut ion of the ha r bou r pre- sents a n u m b e r of serious problems for the heal th authori t ies and ECD. As one public heal th inspector put it:

We've had cholera sitting on our doorstep for a little while, you know. I'm very nervous about what could hap- pen if we had a cholera outbreak. With the amount of sanitation problems we have . . . . we're hanging on by our fingernails.

There was agreement among the heal th pro-

fessionals interviewed that there has been a serious decline in public heal th s tandards. It was said tha t this si tuation is likely to get worse. For years the

Nat ional Water Commiss ion subsidised sani ta t ion and provided clean accessible water. As par t of structural adjus tment the World Bank has required the Nat iona l Water Commiss ion to run at a profit. This specific condi t ion had to be complied with before fur ther loans were given to Jamaica. Senior officials at the Ministry of Heal th were in no doub t abou t the negative effects this par t icular condi t ion will have on health. One senior health official

explained:

One of the dictates of structural adjustment is that all enti- ties must run at a profit. 1 have no problem with that. However, when it comes to the National Water Commission, it means, and the head of the NWC actually went on television and made this statement during a debate on typhoid, he said quite clearly that he is not able to provide clean drinking water to all that need it, because some people can't pay for it. Now that means that if you are poor and you can't pay for clean drinking water, you have to drink dirty water, which gives you disease, which puts you back on our system, our health system. So for example, l attribute the typhoid epidemic in Savanna-la- Mar fair and square on the deterioration of the environmental situation: the quality of the water and the efficiency of sewage disposal. That's what causes typhoid. It's a breakdown in your social environmental structure.

Q. And are you saying that this is related to structural adjustment?

A. Oh yes. Oh yes, absolutely. The water and sanitation situation is because the World Bank requires the Water Commission to run at a profit.

To date, the deter iorat ing envi ronmenta l heal th si tuat ion has not been reflected in quant i ta t ive research accounts of the effects of structural adjustment in Jamaica. Nei ther have the effects of structural ad jus tment on the quality of ECD services and their ability to cope with the growing environ- menta l problems been reflected in quant i ta t ive research. The quali tat ive data presented in the sec- t ions above strongly indicate tha t structural adjustment has had a number of negative repercussions for the quality of pr imary heal th care services and sewage and water provision. It seems clear tha t at a t ime when envi ronmenta l problems are growing,

resources are shrinking and reducing the auth- orities' ability to cope with such problems.

A number of heal th professionals were highly critical of I M F / W o r l d Bank condit ional i ty and quest ioned the legitimacy of such measures. They expressed the view that condit ionali ty raised very deep and fundamenta l questions abou t the role of the state and the loss of nat ional sovereignty. The following comment f rom a senior official illustrates this point:

You are assuming that governments in this country have a certain amount of autonomy and authority over what hap- pens in this country and, in fact, that is no longer so. People jokingly refer to our governments as caretaker governments, because in fact they don't set policies.

Ano the r official had this to say:

It seems to me that in a strange way government and our sovereignty is being starved. We are getting some dribs and drabs from international, multilateral agencies, but we don't have control over that. You have to meet their conditions ... that's increasing. What government has control over that's shrinking. So I think there's a problem.

The Wor ld Bank and I M F argue that the setting of social and political priorities is a mat ter for gov- e rnments and ult imately it is governments who decide on the dis t r ibut ion of resources. Many informants expressed the view that governments have little al ternat ive when allocating resources other than giving priority to the product ive sectors. A senior official sums up this viewpoint well:

I think that's a cop-out argument that government has a choice. They have agreed with external agencies on certain fundamental questions to restructure the economy. So that is where everything starts -at structural adjustment programmes. The whole structural adjustment thing is based on the premise that what you have to do is reduce consumption and increase production by giving all the subsidies to the productive sector. O.K., that is the underlying premise. So if you are to achieve this objective of increasing production it is foolhardy for someone to say that you can choose to continue to fund health and education and then expect to increase production. It's not possible for our government to make a decision to maintain or improve expenditure in health or education: those sectors in terms of financial analysis at the end of year one or two are consumption sectors. So it's a very circular argument and I do not accept it.

The quali tat ive data presented in this paper indicate tha t there have been negative consequences of re-structuring on heal th care provision. In part icular there is evidence to indicate deter iorat ion in the quali ty of heal th services. While the World Bank argues tha t improvements in service delivery must come from increasing efficiency and reduction of waste, these views seem far out of touch with the reality of the s i tuat ion in Jamaica.

SUMMARY AND CONCLUSIONS

Each method has its s t rengths and weaknesses, especially when considered in relat ion to a part icular problem. In this paper some of the l imitat ions


of existing quantitative data were considered. I

examined the most recent longitudinal official data on health inputs and outputs in Jamaica in an effort to establish whether there has been any deterioration in health and health care provision. Reliance on official data of questionable accuracy was highlighted as a problem. In addition, it was argued that, while recognising the value of quantitative research, it has serious limitations in illustrat- ing what is really taking place 'on the ground' in a given country with regards to structural adjustment.

The paper raises important questions about the methods and data used for judging the impact of structural adjustment. It was argued that qualitative research techniques should be used to study the effects of adjustment on health care provision. This it was argued would help overcome the problems which stem from studies relying solely upon quantitative data. While not claiming to be an exhaustive study, and not claiming to provide additional insights into the impact of structural adjustment on health itself, the qualitative data presented in this paper indicate the existence of negative consequences of re-structuring on health care provision. In particular evidence was presented which raises important questions about the deteriorating quality of health services in Jamaica. Research informed by quantitative data has not captured such important information.

The unproven causal relationship between structural adjustment and the decline in health 'outputs ' and methodological difficulties of accuracy give rise to problems in conclusively proving one's case in terms of ~hard' data. However, from the evidence presented those actually working in the health care system and experiencing adjustment first-hand are in no doubt that adjustment has had negative effects on health care provision and social welfare. As a result of cuts in social spending health care staff are experiencing considerable difficulties in delivering the full range of duties associated with the primary health care model. Many perceived a growing threat to health standards and an erosion of previous achievements as a consequence of the adjustment process. Nowhere was this more evident than in the environmental health situation. It is my contention that the utilisation of qualitative research techniques offer important insights into what local people perceive to be the impact of structural adjustment policies. These perceptions are valid and worthy of further research.

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Limitations of quantitative research in the study of structural adjustment

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